Concurrent Anemia Research Articles

The clinical consequences and challenges of hypertension in urban-dwelling black Africans: Insights from the Heart of Soweto Study

There is a paucity of data to describe advanced forms of cardiovascular disease (CVD) in urban black Africans with hypertension (HT). Chris Hani Baragwanath Hospital services the black African community of 1.1 million people in Soweto, South Africa. We prospectively collected detailed demographic and clinical data from all de novo presentations to the hospital's Cardiology Unit in 2006. Overall, 761 black African patients (56% of de novo cases) presented with a diagnosis of HT with more women (63%, aged 58.5±14.9 years) than men (aged 58.0±15.6 years). On presentation, 396 women (82%) versus 187 men (67%) had dizziness, palpitations and/or chest pain (OR 1.23, 95% 1.12-1.34: p<0.0001). HT was the primary diagnosis in 266 cases (35%). In the rest (n=495), non-ischaemic forms of heart failure were common (54% of total) while only 6.2% had coronary artery disease. Concurrent left ventricular hypertrophy, renal dysfunction and anaemia were present in 39%, 24% and 11% of cases, respectively, with a similar age-adjusted pattern of co-morbidity according to sex. However, men were more likely to present with impaired systolic function (OR 2.13, 95% CI 1.50 to 3.00; p<0.0001). In the absence of effective primary and secondary prevention strategies, these unique data highlight the potentially devastating impact of advanced forms of hypertensive heart disease in urban black African communities with more women than men affected.

Predominance of Heart Failure in the Heart of Soweto Study Cohort

There is a paucity of data to describe the clinical characteristics of heart failure (HF) in urban African communities in epidemiological transition. Chris Hani Baragwanath Hospital services the 1.1 million black African community of Soweto, South Africa. Of 1,960 cases of HF and related cardiomyopathies in 2006, we prospectively collected detailed demographic and clinical data from all 844 de novo presentations (43%). Mean age was 55 +/- 16 years, and women (479 [57%]) and black Africans (739 [88%]) predominated. Most (761 [90%]) had > or =1 cardiovascular risk. Mean left ventricular ejection fraction was 45 +/- 18%. Overall, 180 patients (23%) had isolated diastolic dysfunction, 234 (28%) tricuspid regurgitation, 121 (14%) isolated right HF, and 100 (12%) mitral regurgitation. The most common diagnoses were hypertensive HF (281 [33%]), idiopathic dilated cardiomyopathy (237 [28%]), and, surprisingly, right HF (225 [27%]). Black Africans had less ischemic cardiomyopathy (adjusted odds ratio, 0.12; 95% CI, 0.07 to 0.20) but more idiopathic and other causes of cardiomyopathy (adjusted odds ratio, 4.80; 95% CI, 2.57 to 8.93). Concurrent renal dysfunction, anemia, and atrial fibrillation were found in 172 (25%), 72 (10%), and 53 (6.3%) cases, respectively. These contemporary data highlight the multiple challenges of preventing and managing an increasing and complex burden of HF in urban Africa. In addition to tackling antecedent hypertension, a predominance of young women and a large component of right HF predicate the development of tailored therapeutic strategies.

Hemoglobin Decline and Health Outcomes in the Elderly: the Cardiovascular Health Study

Introduction: Anemia is associated with increased morbidity and mortality in the elderly, though the risk factors for and the consequences of hemoglobin (HGB) decline are poorly characterized.Methods: We studied 5201 men and women ≥65 participating in the Cardiovascular Health Study. The cohort was followed biannually and had baseline and repeat hemograms 3 years later. HGB decline was defined as>1g/dL HGB drop, orincident anemia at 3 years by WHO criteria.Results: 4006 participants survived to 3 years and had two HGB measures. The median HGB change was −0.2g/dL (IQR-0.8, 0.1). 961 (24%) participants had a >1g/dL HGB drop and 335 (8%) developed incident anemia. The left side of the table presents adjusted logistic regression models of baseline risk factors for HGB decline. Those with baseline cardiovascular disease (CVD), diabetes and kidney disease were more likely to develop >1g/dL HGB drop while only baseline kidney disease was associated with incident anemia. The table also shows the adjusted risk of HGB decline with concurrent development of co-morbid conditions. A >1g/dL drop in HGB was more likely in those who concurrently developed incident CVD, hypertension or inflammation. Incident anemia was more likely in participants with concurrent development of kidney disease or inflammation. Both incident anemia and a HGB drop >1g/dL were associated with subsequent 9-year mortality adjusting for age, race, gender, year 3 HGB, hypertension, CVD, diabetes, and renal disease; HRs (95% CI) 1.4 (1.2, 1.6) and 1.2 (1.1, 1.4) respectively.Discussion: Among studied factors, baseline CVD, diabetes and kidney disease were risk factors for >1g/dL HGB drop while only baseline kidney disease was a risk factor for incident anemia. Incident CVD and hypertension were associated concurrently with >1g/dL HGB drop while kidney disease was associated with concurrent incident anemia. Inflammation development was the strongest risk factor accompanying HGB decline. HGB decline, especially a 1g/dL drop, was associated with subsequent mortality irrespective of HGB concentration. These data suggest that small HGB changes not captured by the WHO anemia criteria are associated with poor health outcomes and that inflammation is a major correlate of HGB decline in the elderly.Table: Risk Factors for HGB Decline in Age-, Race-, Gender, and Baseline HGB-Adjusted Logistic Regression ModelsBaseline Risk Factors for HGB DeclineRisk of HGB Decline with Concurrent ConditionsHGB Drop >1g/dLIncident AnemiaHGB Drop >1g/dLIncident AnemiaCVD1.2 (1.1, 1.4)1.0 (0.8, 1.3)1.3 (1.1, 1.6)1.0 (0.7, 1.3)Hypertension1.1 (0.99, 1.3)1.1 (0.8, 1.2)1.4 (1.1, 1.7)1.1 (0.8, 1.5)Diabetes1.3 (1.1, 1.5)1.1 (0.8, 1.4)0.9 (0.6, 1.4)0.8 (0.4, 1.7)Kidney Disease (GFR <60ml/min/1.73m2)1.2 (1.0, 1.3)1.3 (1.1, 1.7)1.1 (0.8, 1.4)1.5 (1.0, 2.1)Inflammation CRP ≥10mg/dL or WBC≥15×109/mm31.0 (0.8, 1.3)1.3 (0.99 1.8)2.3 (1.8, 2.8)2.3 (1.8, 3.0)

Concurrent immune-mediated haemolytic anaemia and severe thrombocytopenia in 21 dogs

The medical records of 21 dogs with concurrent immune-mediated haemolytic anaemia (imha) and severe thrombocytopenia (defined as an automated platelet count of less than 50 × 109/l, confirmed by the...

Dendritic cell leukemia in a Golden Retriever

An 8-year-old castrated male Golden Retriever was evaluated for decreased appetite, lethargy, and labored breathing of 1-week duration. Bilateral pulmonary infiltrates, hepatomegaly, and splenomegaly were present. Results of a CBC revealed marked leukocytosis (62,600/microL; reference interval 4000-15,500/microL) and large numbers of atypical cells (30,700/microL) with abundant cytoplasm. There was no concurrent anemia, neutropenia, or thrombocytopenia. Morphology of the atypical cells was most consistent with a histiocytic origin. Similar cells were identified in bone marrow aspirates, and were morphologically suggestive of the macrophage variant of disseminated histiocytic sarcoma. However, flow cytometry of the abnormal circulating cells revealed CD1c, CD11c, and major histocompatibility complex (MHC) Class II expression without expression of CD11d or lymphoid markers, consistent with myeloid dendritic antigen-presenting cells. At necropsy, the splenic architecture was effaced by neoplastic histiocytes that were also infiltrating lung, liver, an abdominal lymph node, myocardium, an bone marrow. Immunohistochemistry of the splenic neoplastic cells confirmed dendritic cell origin (CD1c+, CD11c+, MHC II+, no expression of CD11d and lymphoid markers). To the authors' knowledge, this is the first report of canine dendritic cell leukemia-in this instance accompanied by marked tissue infiltration.

Variants in Iron Metabolism Genes Predict Higher Blood Lead Levels in Young Children

BackgroundGiven the association between iron deficiency and lead absorption, we hypothesized that variants in iron metabolism genes would predict higher blood lead levels in young children.ObjectiveWe examined the association between common missense variants in the hemochromatosis (HFE) and transferrin (TF) genes and blood lead levels in 422 Mexican children.MethodsArchived umbilical cord blood samples were genotyped for HFE (H63D and C282Y) and TF (P570S) variants. Blood lead was measured at 24, 30, 36, 42, and 48 months of age. A total of 341 subjects had at least one follow-up blood lead level available and data available on covariates of interest for inclusion in the longitudinal analyses. We used random-effects models to examine the associations between genotype (HFE, TF, and combined HFE + TF) and repeated measures of blood lead, adjusting for maternal blood lead at delivery and child’s concurrent anemia status.ResultsOf 422 children genotyped, 17.7, 3.3, and 18.9% carried the HFE H63D, HFE C282Y, and TF P570S variants, respectively. One percent of children carried both the HFE C282Y and TF P570S variants, and 3% of children carried both the HFE H63D and TF P570S variants. On average, carriers of either the HFE (β = 0.11, p = 0.04) or TF (β = 0.10, p = 0.08) variant had blood lead levels that were 11% and 10% higher, respectively, than wild-type subjects. In models examining the dose effect, subjects carrying both variants (β = 0.41, p = 0.006) had blood lead 50% higher than wild-type subjects and a significantly higher odds of having a blood lead level > 10 μg/dL (odds ratio = 18.3; 95% confidence interval, 1.9–177.1).ConclusionsIron metabolism gene variants modify lead metabolism such that HFE variants are associated with increased blood lead levels in young children. The joint presence of variant alleles in the HFE and TF genes showed the greatest effect, suggesting a gene-by-gene-by-environment interaction.

Carbamazepine-Induced Hemolytic and Aplastic Crises Associated with Reduced Glutathione Peroxidase Activity of Erythrocytes

Although pure red cell aplasia is a well-known side effect of carbamazepine treatment, intravascular hemolytic anemia is rare. We describe a 5-year-old boy who developed concurrent intravascular hemolytic anemia and erythroblastopenia, probably due to carbamazepine. Carbamazepine treatment was subsequently discontinued, and the patient was treated with red blood cell transfusions, haptoglobin, and methylprednisolone. His hematologic abnormalities were almost fully recovered within 2 weeks. Examination of the patient's and mother's erythrocyte enzyme activities revealed mildly decreased erythrocyte glutathione peroxidase (GSH-Px) activity. We speculate that patients with reduced GSH-Px activity are at a high risk of developing carbamazepine-induced hemolytic crisis and/or aplastic crisis.

Severe Anemia, Panserositis, and Cryptogenic Hepatitis in an HIV Patient Infected with Bartonella henselae

Bartonella spp. constitute emerging pathogens of worldwide distribution. Bacillary angiomatosis is the most frequent skin manifestation of bartonelloses; nevertheless, B. henselae infection should always be considered systemic, especially in immunodeficient individuals. The authors report the case of an AIDS patient with bacillary angiomatosis, who had concurrent severe anemia, hepatitis, peritonitis, pleuritis, and pericarditis. Clinical manifestation, electronic microscopic examination of erythrocytes, and histopathology of a papule biopsy suggested a Bartonella sp. infection. Multiple genes were target by PCR and B. henselae DNA was amplified and sequenced (GenBank accession number EF196804) from the angiomatous papule. Treatment with clarithromycin resulted in resolution of the bacillary angiomatosis, fever, anemia, panserosites, and hepatitis.

Are lower gastrointestinal investigations necessary in patients with coeliac disease?

Colonoscopy may be indicated in patients with coeliac disease who present with iron deficiency anaemia or in coeliac disease patients who have persisting diarrhoea despite being on a gluten-free diet. However, there are limited data to support this approach. We prospectively recruited patients who were found to have coeliac disease, having been referred with newly diagnosed iron deficiency anaemia. We also recruited a second group of patients with known coeliac disease. These patients had persisting diarrhoea despite being on a gluten-free diet for 6 months. All patients had colonoscopy and were matched with controls (without coeliac disease) who had similar indications for colonoscopy. Ninety-eight consecutive new patients with coeliac disease and concurrent iron deficiency anaemia had colonoscopy performed. Twelve (12.2%) had pathology, three of which were carcinomas. This diagnostic yield was not significantly different from the findings in the control group 62/362 (17.1%) P=0.24. In coeliac disease patients with persisting diarrhoea (n=37), the diagnostic yield at colonoscopy was 1/37 (2.7%). This was significantly lower than our findings in the control group with chronic diarrhoea 55/390 (14%) P=0.05. Colonoscopy should be considered in patients with coeliac disease (over the age of 45 years) who present with iron deficiency anaemia. Whilst, for coeliac disease patients with persisting diarrhoea (on a gluten-free diet) in the absence of sinister symptoms, a flexible sigmoidoscopy may be the initial investigation in order to exclude microscopic colitis. However, further larger prospective studies are required to evaluate this approach.

Autoimmune disorders in Kabuki syndrome

Kabuki syndrome is associated with abnormalities in multiple organ systems. While many of the anomalies are congenital malformations, other clinical manifestations may not appear until later in childhood. Among these associated conditions, autoimmune abnormalities have been described in several patients. These include idiopathic thrombocytopenic purpura (ITP), hemolytic anemia, thyroiditis, and vitiligo. In this report, we describe five affected patients with autoimmune manifestations. Four patients had ITP, and two of these patients had concurrent hemolytic anemia. The fifth patient had vitiligo. Two of the patients with ITP had a chronic and relapsing course. Of note, some of these patients also had hypogammaglobulinemia. The autoimmune disorders may be manifestations of abnormal immune regulation. We conclude that Kabuki syndrome is associated with an increased incidence of autoimmune disorders. In addition, the presence of an underlying immune defect may predispose these children to a chronic course of these autoimmune conditions.

Biochemical investigations in geophagia

Woywodt and Kiss’ historical review of geophagia1 prompts us to report a study illustrating how, through absorption or liberation of essential minerals, earth when consumed habitually can be either harmful or, possibly, nutritious. The amount of material ingested probably contributes as well. An African woman admitted to hospital with limb paralysis had a serum potassium of 1.3 mmol/L (reference range, 3.5–5.0). Other serum electrolytes were normal. The hypokalaemia and a concurrent iron deficiency anaemia (haemoglobin 7.9 g/dL, serum iron 3.5 μmol/L) remained unaccounted for. Further enquiry disclosed a 10-year history of geophagia. The earth she ingested was obtained from her garden. It was black with white speckles, malleable, rough in texture and composed of granular particles (‘black earth’). Earth excavated locally for eating was obtained from a nearby market. This was dusky pink, firm, fine in texture and composed of flaky particles (‘red earth’). Samples of black earth and red earth weighing 0.5, 1.0 and 2.0 g were mixed with 5 mL iron-enriched Ringer-lactate. Studies were done at both pH 2.0 (addition of 6 mol/L HCl) and pH 6.2. Analyses were performed on a standard system. Black earth absorbed sodium, potassium and iron. It also liberated calcium and magnesium. These effects were present at either pH. Red earth absorbed potassium, slightly, at either pH. Iron was liberated at pH 2.0 and absorbed at pH 6.2. Other elements showed small differences only. Changes for black earth and for red earth were proportionate to mass concentration. (Full details can be had from RFG.) Our patient’s intake of potassium conformed to the recommended dietary allowance (RDA) and that of iron was deficient (44% of RDA). The demonstrated absorbent properties for potassium and for iron of black earth indeed could thereby have caused her hypokalaemic paralysis and contributed to her iron deficiency anaemia. Absorbent properties for sodium of black earth, though notable, were not homoeostatically significant. Intake was estimated at only 7.5% of dietary guidelines, yet the serum concentration was normal. The same applies to magnesium. This was liberated from black earth in quite large amounts, dietary intake exceeded the RDA (120%) and yet the serum concentration again was normal. Intake of calcium was below the RDA (43.5%), while the serum concentration was normal. Possibly, the calcium liberated from black earth actually functioned as a dietary supplement.2–4 The local African population believes that ingestion of earth benefits women when they become pregnant. Red earth indeed had properties that might prevent iron deficiency anaemia, though the bioavailability of this (non-haem, contaminant) iron may be limited.5 Before attributing any adverse or beneficial consequences to geophagia, the ion-exchange capacity6 of the substance in question should be evaluated. That is within the scope of most hospital laboratories.

Molecular Profiling of Anemia in Acute Renal Allograft Rejection Using DNA Microarrays

Compromised renal function after renal allograft transplantation often results in anemia in the recipient. Molecular mechanisms leading to anemia during acute rejection are not fully understood; inadequate erythropoietin production and iron deficiency have been reported to be the main contributors. To increase our understanding of the molecular events underlying anemia in acute rejection, we analyzed the gene expression profiles of peripheral blood lymphocytes (PBL) from four pediatric renal allograft recipients with acute rejection and concurrent anemia, using DNA microarrays containing 9000 human cDNA clones (representing 7469 unique genes). In these anemic rejecting patients, an 'erythropoiesis cluster' of 11 down-regulated genes was identified, involved in hemoglobin transcription and synthesis, iron and folate binding and transport. Additionally, some alloimmune response genes were simultaneously down-regulated. An independent data set of 36 PBL samples, some with acute rejection and some with concurrence of acute rejection and anemia, were analyzed to support a possible association between acute rejection and anemia. In conclusion, analysis using DNA microarrays has identified a cluster of genes related to hemoglobin synthesis and/or erythropoeisis that was altered in kidneys with renal allograft rejection compared with normal kidneys. The possible relationship between alterations in the expression of this cluster, reduced renal function, the alloimmune process itself, and other influences on the renal transplant awaits further analysis.

Low serum vitamin B12 is common in coeliac disease and is not due to autoimmune gastritis

Although coeliac disease is a disorder of the proximal small bowel, associated vitamin B12 deficiency has been reported. This study aimed to assess the prevalence of B12 deficiency in a large series of coeliac patients, and to exclude the possibility that it is due to associated autoimmune gastritis. Prospective routine measurement of serum B12 in coeliac patients, with investigations for pernicious anaemia/autoimmune gastritis in B12-deficient patients. Gastroenterology department of a large district general hospital. If they were not taking vitamin B12 supplements already, patients had serum B12 measured before starting dietary gluten exclusion. Those with low levels also had gastric biopsies taken and plasma gastrin and serum gastric parietal cell and intrinsic factor antibodies measured. Prevalence of low serum B12, and presence or absence of indicators of pernicious anaemia/autoimmune gastritis in patients with low serum B12. Of 159 patients, 13 had low serum B12 at diagnosis. A further six had been receiving B12 replacement therapy for 3-37 years before diagnosis, giving an overall prevalence of 12% (19 patients). Only 2/19 patients had gastric corpus atrophy, one with intrinsic factor antibodies and the other with hypergastrinaemia. There was no relationship between low B12 and clinical characteristics. Low B12 is common in coeliac disease without concurrent pernicious anaemia, and may be a presenting manifestation. B12 status should be known before folic acid replacement is started.

Cardiac Troponins in Canine Babesiosis

This study compared the sensitivity of ECG and cardiac troponins to predict cardiac histopathological changes, clinical severity, and survival in canine babesiosis. One control group (n = 9) and 4 groups of dogs with mild uncomplicated babesiosis (n = 8), severe uncomplicated babesiosis (n = 9), complicated babesiosis (n = 8), and babesiosis and concurrent immune‐mediated he‐molytic anemia (IMHA) (n = 9) were studied. A 1‐minute lead II ECG was recorded, and cardiac troponin I (cTnl) and T (cTnT) concentrations in plasma were measured. cTnl concentrations were significantly higher in the complicated (mean, 9.9; SE, ±5.76) and concurrent IMHA (mean, 6.53; SE, ±4.32) groups and in the 3 dogs that died of the disease (mean, 22.17; SE, ±12.85) than in the control dogs (concentration below detection limit of test, —0.3 ng/mL). The 3 nonsurvivors had the most severe cardiac histopathological changes, but no arrhythmia and minimal other ECG changes. Dogs with babesiosis developed a variety of ECG abnormalities, but the abnormalities were not associated with disease severity, outcome, or plasma cardiac troponin concentrations. The exception was the presence of ventricular premature complexes (VPCs), which were associated with high cardiac troponin concentrations. This study showed an association between cTnl concentration and histological changes, clinical severity, and survival and no correlation between ECG abnormalities and histological changes or biochemical evidence of myocardial damage as reflected by cTnl concentrations. From this study, it was concluded that the analysis of plasma cTnl is a feasible and sensitive test and is superior to cTnT in diagnosing cardiac involvement in dogs with babesiosis.

Prevalence of iron deficiency with and without concurrent anemia in population groups with high prevalences of malaria and other infections: a study in Côte d’Ivoire

Iron deficiency is highly prevalent in most developing countries. However, its detection is often obscured by infections and inflammatory disorders that are common in the same populations. The aim of this study was to estimate the prevalence of iron deficiency with or without concurrent anemia in different population groups from Côte d'Ivoire and to evaluate the influence of infectious and inflammatory disorders on iron-status indexes. Blood samples from 1573 children, women, and men were analyzed for hemoglobin, serum ferritin, zinc protoporphyrin, and serum transferrin receptor. C-reactive protein was used as the indicator of inflammation or infection, and samples were screened for malarial parasites and hemoglobinopathies. Iron deficiency was defined as 2 of 3 iron-status indexes outside the cutoff values, and iron deficiency anemia (IDA) was defined as iron deficiency with concurrent anemia. Pearson's correlation coefficients were used to evaluate the influence of malaria and inflammation on iron-status indexes. The prevalence of iron deficiency was 41-63% in the women and children and 13% in the men, whereas the prevalence of IDA was 20-39% in the women and children and 4% in the men. The detection of iron deficiency and IDA was obscured by the high prevalence of inflammatory disorders. Iron deficiency and IDA are highly prevalent in the women and children in Côte d'Ivoire. Iron deficiency was detected in approximately 50% of anemic women and children, which indicates that hemoglobin alone is not a good indicator of iron status when inflammatory disorders are highly prevalent. The serum transferrin receptor is the most useful single indicator of iron deficiency because it was the only iron-status index unaffected by malaria or inflammation.

Subadult health and disease in prehistoric Tonga, Polynesia.

This article focuses on the differential diagnosis of pathologic lesions recorded on the limbs and crania of 17 subadults from two pre-European burial mounds in Tonga, western Polynesia. All affected subadults were between the ages of 6 months and 3 years at death. The lesions described consist primarily of subperiosteal new bone deposition on the limbs and endocranial surface. However, the presence of cribra orbitalia in a number of individuals indicates concurrent iron-deficiency anaemia. A differential diagnosis of haematogenous osteomyelitis, congenital syphilis, yaws, scurvy, hypervitaminosis A, trauma, Caffey's disease, and iron-deficiency anaemia is discussed. It was concluded that the most likely cause for the lesions observed is a synergistic relation between infection (weanling diarrhoea, yaws) and metabolic disease (scurvy and possibly hypervitaminosis A). Trauma is not ruled out as contributing to the development of some pathologic lesions. It is concluded that, in the Pacific Islands at least, multiple causes for skeletal pathology in subadults should be considered rather than a single aetiology.

Western immunoblot analysis of the antigens of Haemobartonella felis with sera from experimentally infected cats.

Cats were experimentally infected with a Florida isolate of Haemobartonella felis in order to collect organisms and evaluate the immune response to H. felis. Cryopreserved organisms were thawed and injected intravenously into nonsplenectomized and splenectomized cats. Splenectomized animals were given 10 mg of methylprednisolone per ml at the time of inoculation. Blood films were evaluated daily for 1 week prior to infection and for up to 60 days postinfection (p. i.). Blood for H. felis purification was repeatedly collected from splenectomized animals at periods of peak parasitemias. Organisms were purified from infected blood by differential centrifugation, separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and transferred to nitrocellulose membranes for immunoblot analysis. Serum was collected from nonsplenectomized animals prior to and for up to 60 days p.i. and was used on immunoblots to identify antigens. The combination of splenectomy and corticosteroid treatment resulted in marked, cyclic parasitemias without concurrent severe anemia, providing an opportunity to harvest organisms in a manner that was not lethal to the animals. Several antigens (150, 52, 47, 45, and 14 kDa) were identified. An antigen with a molecular mass of approximately 14 kDa appeared to be one of the most immunodominant and was consistently recognized by immune sera collected at various times during the course of infection. These data suggest that one or more of these antigens might be useful for the serologic diagnosis of H. felis infections in cats.

Successful management of concurrent congenital dyserythropoietic anaemia and autoimmune haemolytic anaemia with splenectomy

This first known case of concurrent congenital dyserythropoietic anaemia (CDA) and autoimmune haemolytic anaemia (AIHA) which occurred in a hispanic male and spanned 6 years from the age of 2. Light and electron microscopy of bone marrow erythroblasts and immunophenotyping confirmed CDA; serum/eluate warm autoantibodies and positive direct antiglobulin tests (DAT) associated with severe, episodic anaemias established AIHA. Cytogenetic analysis of bone marrow cells and peripheral blood lymphocytes ascertained sex chromosome aneuploidy (48 XY,+ Y,+ Y). Recurrent, life-threatening episodes of transfusion-dependent anaemia refractory to steroids and intravenous immune globulin, were put into stable remission at age 8 years when splenectomy successfully managed both disorders.

The predictive value of concurrent anaemia and leukocytosis in the diagnosis of colorectal cancer

The predictive value of concurrent anaemia and leukocytosis in the diagnosis of colorectal cancer

BLEEDING GIANT GASTRIC ULCER

A consecutive series of 269 cases of bleeding gastric ulcer were studied prospectively from 1979 to 1993 inclusive. Fifty-five (21%) had a giant gastric ulcer with a diameter of 3 cm or more. These cases were compared with those with ulcers less than 3 cm in diameter in terms of clinical details, prognostic factors, urgent operation and outcome. Death occurred in 13 cases (5%), urgent surgery was performed in 75 cases (29%) and there were 11 postoperative deaths (15%) within a month of surgery. The patient details in the two groups matched in terms of age, sex distribution, ulcer history, previous complication and recent ingestion of analgesics. Clinical comparison showed that giant ulcer had a poorer prognosis with a higher mortality (10 vs 3%, P < 0.01), urgent surgery rate (65 vs 12%, P < 0.01) and operative mortality (23 vs 11%, difference not significant). Study of risk factors in patients with giant ulcer revealed significantly more with concurrent illness, shock, anaemia and endoscopic stigmata of recent haemorrhage. More severe bleeding and poorer general condition in the giant ulcer group stresses the importance of early diagnosis and accurate resuscitation in these patients. Survival depends on optimal condition and prompt and timely surgery.